Orthopedic Problems Research Articles

Common complications in spinal muscular atrophy (SMA) type 1 after nusinersen treatment.

Spinal muscular atrophy (SMA) is an inherited disease with progressive muscle weakness and atrophy. Despite the new treatments developed recently, primary and secondary effects of muscle weakness in patients with SMA cause mortality and morbidity. The aim of this study is to identify common problems in the follow-up of patients after new treatment modalities and to examine the difficulties in management of these problems. The study included 16 patients diagnosed with SMA type 1 according to clinical findings and genetic results between 2017 and 2022. The patients were divided into two groups as living and deceased, and complications were examined and compared between the groups. The patients comprised 8 (50%) females and 8 (50%) males with a median age at diagnosis of 3 months. The patients had a history of gastrointestinal problems, orthopedic problems, infection and sepsis, and especially respiratory distress. Death occurred in 8 (50%) patients during follow-up (median age 38 months). Mortality was higher in patients who needed tracheostomy and had gastroesophageal reflux. The survival rate was better in patients who received more nusinersen treatment and had a higher CHOP-INTEND score. Despite new-generation treatments for SMA type 1, morbidity and mortality rates remain very high. As the survival rate in SMA type 1 increases, the incidence of complications similar to those frequently seen in SMA type 2 and type 3 patients also increases. The follow-up and treatment of patients with SMA should be undertaken by a multidisciplinary team.

Anterior Glenohumeral Instability

➢ Anterior glenohumeral instability is a complex orthopaedic problem that requires a detailed history, a thorough physical examination, and a meticulous review of advanced imaging in order to make individualized treatment decisions and optimize patient outcomes.➢ Nonoperative management of primary instability events can be considered in low-demand patients, including elderly individuals or younger, recreational athletes not participating in high-risk activities, and select in-season athletes. Recurrence can result in increased severity of soft-tissue and osseous damage, further increasing the complexity of subsequent surgical management.➢ Surgical stabilization following primary anterior instability is recommended in young athletes who have additional risk factors for failure, including participation in high-risk sports, hyperlaxity, and presence of bipolar bone loss, defined as the presence of both glenoid (anteroinferior glenoid) and humeral head (Hill-Sachs deformity) bone loss.➢ Several surgical treatment options exist, including arthroscopic Bankart repair with or without additional procedures such as remplissage, open Bankart repair, and osseous restoration procedures, including the Latarjet procedure.➢ Favorable results can be expected following arthroscopic Bankart repair with minimal (<13.5%) bone loss and on-track Hill-Sachs lesions following a primary instability event. However, adjunct procedures such as remplissage should be performed for off-track lesions and should be considered in the setting of subcritical glenoid bone loss, select high-risk patients, and near-track lesions.➢ Bone-grafting of anterior glenoid defects, including autograft and allograft options, should be considered in cases with >20% glenoid bone loss.

Avascular necrosis of femoral head – Demographic profile, natural history of asymptomatic hips and native hip survivorship in an indian subcontinent cohort

BackgroundAvascular Necrosis of the femoral head is still considered an unsolved orthopedic problem despite significant research and advances in treatment. Purposes1.Describe the demographic pattern2.Assess postoperative survival of the native hip3.Observe the natural history in asymptomatic hips Patients and methodsA South Indian quaternary care hospital based retrospective study. Patients diagnosed with non-traumatic avascular necrosis of the femoral head who underwent hip-preserving procedures between 2004 and 2017 were studied. The clinical and radiological outcomes were assessed. Statistical analysis for hip survival was done using Kaplan–Meier survival analysis. ResultsThe study was conducted on 306 hips of 190 patients. The most common etiology was steroid intake. The average follow-up period was 8 years. 216(76 %) hips survived clinically and 125(44 %) hips survived radiologically. The mean duration of clinical survival was 8 years and radiological survival was 7.5 years. The overall regression was highest in the fibula grafting. In asymptomatic hips clinical failure was observed in 36(53 %) hips and radiological failure in 52(77 %) hips with a mean follow-up of 5.9 years. ConclusionThe earlier stage of presentation and a hip-preserving surgery exhibited a 70 % chance of survival of the native hip. Core decompression decreased the rate of progression in the early stages. Disease regression rates were significant in fibula grafting for stages 2a and 2b. Non-operative treatment is not advisable given rapid disease progression.

The Intricate Interplay in Gut-brain Axis and Orthopedic Problems

The Intricate Interplay in Gut-brain Axis and Orthopedic Problems

Hypergravity as a Possible Way of Bone Tissue Engineering in Osteoblastic Differentiation from Mesenchymal Stem Cells: A Systematic Review

Background: Tissue engineering development has become a highlight in recent decades. One of the key areas of focus is producing mature bone tissue to overcome orthopedic problems, such as bone defects. Various cultures have been implemented on stem cells; some induce osteoblastic differentiation markers, while others have the opposite effect. Microgravity has been proven in several studies to inhibit the expression of osteogenic differentiation markers. Conversely, hypergravity is expected to have the opposite impact, supporting stem cells in the osteogenesis pathway. Methods: A literature search was conducted using online databases including Sciencedirect, PubMed, and Proquest, covering the period from 2008 to 2022. This search considered only experimental studies published in English. The keywords used in this research were "hypergravity" and "mesenchymal stem cell." All acquired data were processed and analyzed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (2020). Results: Initially, 190 studies were collected from online databases based on relevant keywords. After screening, 5 studies were included in the final analysis, focusing on hypergravity treatment and its effects on mesenchymal stem cells (MSCs). Conclusion: Hypergravity shows a significant and strong impact on osteoblastic differentiation. This study revealed that a gravity force of 30G and a culture duration of 7 to 14 days are the most optimal combination for inducing osteoblastic differentiation in MSCs.

Body Mass Index is Related to Femoral Anteversion, Hip Rotation During Gait, and Passive Hip Range of Motion in Children and Adolescents.

Overweight and obesity are major global health issues, often linked to orthopaedic problems, skeletal malalignments, and altered gait biomechanics. However, skeletal and biomechanical adaptions in the transverse plane remain underexplored. Therefore, this study aimed to investigate the relationship between body mass index (BMI) and variables describing lower extremity torsional profiles, hip rotation mobility, and transverse plane gait characteristics in children and adolescents. Acetabular and femoral anteversion, tibial torsion (measured through computed tomography), hip and knee rotation, and foot progression angles during the stance phase of gait (measured by 3D gait analysis), as well as passive hip rotation range of motion (evaluated as the midpoint of hip rotation in clinical examination), were retrospectively analyzed in 122 children and adolescents. Correlations between all variables and logit-transformed BMI percentiles were calculated. Moderate correlations were found between BMI percentile and hip rotation during the stance phase (r=-0.68, P<0.001), the passive midpoint of hip rotation (r=-0.51, P<0.001), and femoral anteversion (r=-0.50, P<0.001). Small correlations were observed for acetabular anteversion (r=-0.36, P<0.001), knee rotation during stance phase (r=0.34, P<0.001), and foot progression angle during stance phase (r=-0.31, P<0.001). Tibial torsion showed a nonsignificant negligible relationship with BMI percentile (r=-0.26, P=0.004). BMI percentile was positively correlated with external hip rotation during the stance phase of gait and passive external hip rotation, and negatively correlated with femoral anteversion. These findings suggest abnormal body weight is associated with static and dynamic biomechanical alterations. Therefore, weight management should be considered in orthopaedic assessments and treatment planning for children and adolescents.

Chitosan-glucose derivative membrane obtained by Maillard reaction improves cartilage repair in a rabbit model

BackgroundTreatment of articular cartilage injury remains a challenging clinical problem in orthopedics. Chitosan-derived biomaterial could be a potential adjuvant treatment to improve cartilage repair. In the current study, we examined the effects of two potential chitosan-derived materials on cartilage regeneration of osteochondral defects in rabbits.MethodsAn osteochondral defect was created over the rabbit knee and treated using three approaches: group A received no material (n = 24), group B received chitosan membranes with glucose absorption (CGA; n = 25), and group C received chitosan-glucose derivative membranes obtained via the Maillard reaction (CGMR; n = 25). Cartilage repair over the osteochondral defect was analyzed 12 weeks post-surgery via histological analysis, immunostaining, and reverse transcription-qualitative polymerase chain reaction (RT-qPCR) for type-I and type-II collagen mRNA.ResultsAccording to histological analysis, CGMR-treated defects showed significantly improved modified O’Driscoll scoring when compared with no material- and CGA-treated defects (20.9 ± 4.3 vs. 13.00 ± 2.5 and 17.7 ± 4.6, p < 0.001). Moreover, group C exhibited higher intensity of type-II collagen immunohistochemical staining over the regenerated cartilage than groups A and B, along with increased expression of type-II collagen mRNA by RT-qPCR.ConclusionsCGMR might improve cartilage regeneration in osteochondral defects.

A Survey of Medical Visualization Through the Lens of Metaphors.

We provide an overview of metaphors that were used in medical visualization and related user interfaces. Metaphors are employed to translate concepts from a source domain to a target domain. The survey is grounded in a discussion of metaphor-based design involving the identification and reflection of candidate metaphors. We consider metaphors that have a source domain in one branch of medicine, e.g., the virtual mirror that solves problems in orthopedics and laparoscopy with a mirror that resembles the dentist's mirror. Other metaphors employ the physical world as the source domain, such as crepuscular rays that inspire a solution for access planning in tumor therapy. Aviation is another source of inspiration, leading to metaphors, such as surgical cockpits, surgical control towers, and surgery navigation according to an instrument flight. This paper should raise awareness for metaphors and their potential to focus the design of computer-assisted systems on useful features and a positive user experience. Limitations and potential drawbacks of a metaphor-based user interface design for medical applications are also considered.

Comparative Study between Dynamic Hip Screw (DHS) with Lateral Stabilizing Plate versus Proximal Femoral Nail (PFN) in Fixation of Unstable Intertrochanteric Fractures. A Systematic Review &amp; Meta-Analysis

Abstract Background Intertrochanteric fractures are one of the elementary orthopaedic clinical problems accounting for 7% of osteoporotic fracture. These kind of fractures usually caused by low-energy trauma such as a fall from standing height with several risk factors including; increasing age, female gender, osteoporosis, a history of falls, and gait abnormalities. Usually intertrochanteric fracture is classified according to its stability. Fracture stability is dependent on the status of the posteromedial cortex. Stable fractures are commonly simple fractures which are less affected by vertical stress during one-leg standing. Unstable intertrochanteric fracture has decreased ability to resist stress due to affection of Posteromedial or Lateral femoral cortex. Patients and Methods Asystematic review &amp; Meta analysis was design with a careful consideration of the Cochrane Handbook for Systematic Reviews of Interventions. We also will follow The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines during the design of our study. Population: Patients with unstable Intertrochanteric fractures, intervention: Dynamic hip screws (DHS) with lateral stabilizing plate(TSP), comparator: Proximal Femur Nail, outcome parameters: Functional and radiological, study design: Clinical trials whether randomized or nonrandomized prospective or retrospective cohort, case control studies. Results Use of TSP with DHS can give good results in unstable inter trochanteric fractures. As compared to DHS with TSP, PFN is technically more demanding surgery and in our meta analysis and systematic review study we found complication rate of PFN to be higher as compared to DHS with TSP. Addition of TSP to DHS gives good lateral wall buttress which prevent excessive medialization of shaft and gives comparable result to PFN which is considered as better implant in unstable fractures. Conclusion The current systematic review indicated that there is no statistically significant difference between patients operated with Dynamic Hip Screw with Trochanteric lateral Stabilization Plate and Proximal Femoral Nail.

Comparative study of the outcomes of one-stage versus two-stage reconstruction of chronic multiligament knee injury

BackgroundMulti-ligament knee injury (MLKI) is a complex orthopaedic knee problem, usually following traumatic knee dislocation. Surgical management is preferred and has resulted in better clinical outcomes. However, the optimal surgical treatment protocol is continuously evolving. This study aimed to compare the outcomes of one-stage versus two-stage reconstruction of MLKI. Materials and methodsThis retrospective comparative study was conducted between July 2020 and December 2023 at a government orthopaedic hospital in Nigeria. The inclusion criteria include males and females between 18 and 45 years of age who had one- or two staged knee reconstructions for MLKI and were followed up for a minimum of 12 months. The exclusion criteria were patients below 18 and above 45 years of age, those with previous knee surgery, those associated with femoral or tibia fractures, those with radiological evidence of osteoarthritis, and those with follow-ups less than 12 months. Clinical outcomes using the Lysholm scoring system and complication rate were recorded. The statistical analysis was performed using SPSS version 23. ResultsFifty-one patients (26 in the OS group and 25 in the TS group) were studied. There was a significant difference between the preoperative and postoperative Lysholm scores in the two groups (p = 0.86 and 0.57 for OS and TS, respectively). However, there was no significant difference between the postoperative Lysholm scores in the two groups (p = 0.918). ConclusionOne-stage and two-stage reconstruction of chronic MLKI give similar excellent clinical outcomes.

Refinement of Modified Endoscopic Lateral Soft-Tissue Procedure for Correction of Hallux Valgus Deformity

Hallux valgus is a common orthopaedic problem, and surgical correction frequently is indicated for symptomatic deformity. The modified endoscopic distal soft-tissue procedure has been reported to provide a minimally invasive approach of hallux valgus correction with augmentation of the medial metatarsosesamoid suspensory ligament and intermetatarsal ligament. The purpose of this Technical Note is to describe the refinements of the modified endoscopic distal soft-tissue procedure to achieve more anatomical augmentation of the medial metatarsosesamoid ligament and intermetatarsal ligament, which can provide more stable reconstruction and prevent stiffness of the first metatarsophalangeal joint.

Modern technologies for medical rehabilitation of children with knee joint injuries

Pathology of the knee joint in children is a pressing problem in pediatric traumatology, orthopedics and pediatrics. The frequency of injuries to the knee joint is determined by the complexity of its structure, biomechanical features with a high probability of overload. At the same time, intra-articular injuries in children and adolescents, accounting for up to 7 % in the structure of inpatient pathology, are the cause of pronounced functional disorders of the lower limb and the risk of developing post-traumatic osteoarthritis Currently, physical factors are widely used at various stages of medical rehabilitation of children with damage to the capsular-ligamentous apparatus of the knee joint. The conducted studies have established the effectiveness of using local air cryotherapy in the early postoperative period, characterized by a pronounced anti-edematous, analgesic effect. Early regression of pain and elimination of microcirculatory disorders in the area of injury as a result of a course of pulsed low-frequency magnetic therapy at various stages of medical rehabilitation of children with damage to the capsular-ligamentous apparatus of the knee joint have been recorded. The beneficial effect of a pulsed low-frequency electrostatic field on indicators of orthopedic status, and thermography indicators in the area of injury in children with knee joint injuries has been established. Data were obtained on more pronounced regression of pain, earlier restoration of range of motion in the damaged joint and relief of signs of post-traumatic synovitis with the complex use of a pulsed low-frequency electrostatic field and robotic mechanotherapy in children with damage to the capsular ligamentous apparatus of the knee joint. The obtained clinical and functional results are of great importance for injuries of the knee joint with the risk of contractures in the postoperative period.

Bioactive material‑sodium alginate-polyvinyl alcohol composite film scaffold for bone tissue engineering application

Road accidents and infection-causing diseases during bone surgery are serious problems in orthopedics, and thus, addressing these pressing challenges is crucial. In the present study, the 70S30C calcium silicate bioactive material (BM) is synthesized by a sustainable approach employing a precipitation method using recycled rice husk and eggshells as a precursor of silica and calcium. Further, 70S30C BM is composited with sodium alginate (SA) and polyvinyl alcohol (PVA), and the films were prepared by solvent casting method. The composite films were prepared without the addition of acid, binder, and crosslinking agents. Further, the films were characterized by BET, XRD, ATR-FTIR, SEM, and EDS mapping. The in vitro bioactivity and biodegradation study is performed in the simulated body fluid (SBF). The in vitro haemolysis study is executed using human blood and the results demonstrate haemocompatibility of the composite films. The ex ovo CAM assay also exhibits good neovascularization. The in vitro and in vivo biocompatibility assay proves its non-toxic nature. Further, the in vivo study reveals that the engineered composite film demonstrates accelerated osteogenesis. This work broadens the orthopedic potential of the composite film and offers bioactivity, haemocompatibility, angiogenesis, non-toxicity, and in vivo osteogenesis which would serve as a potential candidate for bone tissue engineering application.

Essential components of an effective transition from paediatric to adult neurologist care for adolescents with Duchenne muscular dystrophy; a consensus derived using the Delphi methodology in Eastern Europe, Greece and Israel

PurposeAn increasing number of patients with Duchenne muscular dystrophy (DMD) now have access to improved standard of care and disease modifying treatments, which improve the clinical course of DMD and extend life expectancy beyond 30 years of age. A key issue for adolescent DMD patients is the transition from paediatric- to adult-oriented healthcare. Adolescents and adults with DMD have unique but highly complex healthcare needs associated with long-term steroid use, orthopaedic, respiratory, cardiac, psychological, and gastrointestinal problems meaning that a comprehensive transition process is required. A sub-optimal transition into adult care can have disruptive and deleterious consequences for a patient’s long-term care. This paper details the results of a consensus amongst clinicians on transitioning adolescent DMD patients from paediatric to adult neurologists that can act as a guide to best practice to ensure patients have continuous comprehensive care at every stage of their journey.MethodsThe consensus was derived using the Delphi methodology. Fifty-three statements were developed by a Steering Group (the authors of this paper) covering seven topics: Define the goals of transition, Preparing the patient, carers/parents and the adult centre, The transition process at the paediatric centre, The multidisciplinary transition summary – Principles, The multidisciplinary transition summary – Content, First visit in the adult centre, Evaluation of transition. The statements were shared with paediatric and adult neurologists across Central Eastern Europe (CEE) as a survey requesting their level of agreement with each statement.ResultsData from 60 responders (54 full responses and six partial responses) were included in the data set analysis. A consensus was agreed across 100% of the statements.ConclusionsIt is hoped that the findings of this survey which sets out agreed best practice statements, and the transfer template documents developed, will be widely used and so facilitate an effective transition from paediatric to adult care for adolescents with DMD.

Research and Application of Chitosan Nanoparticles in Orthopedic Infections.

Orthopedic infection is one of the most intractable orthopedic problems. Bacteria resistant to antibiotics also develop gradually. Chitosan is widely used in the Biomedical field because of its high biocompatibility, biodegradability, and antibacterial activity. Chitosan-based drug delivery systems are frequently utilized to produce controlled medication release. When combined with antibiotics, synergistic antibacterial effects can be achieved. Chitosan-based nanoparticles are one of the most widely used applications in drug delivery systems. The focus of this review is to provide information on new methods being developed for chitosan-based nanoparticles in the field of bone infection treatment, including chitosan nanoparticles for antibacterial purposes, Ch-loaded with antibiotics, Ch-loaded with metal, and used as immune adjuvants. It may Provide ideas for the fundamental research and the prospects of future clinical applications of orthopedic infections.

The Clinical Results of Percutaneous Drilling in the Treatment of Chronic Lateral Epicondylitis.

Lateral epicondylitis is one of the leading orthopedic problems encountered in daily practice. Treatments are more symptomatic than curative. Percutaneous drilling is a minimally invasive method that provides satisfactory results. The aim of this study was to evaluate patients who had undergone percutaneous drilling for chronic lateral epicondylitis. The study included 31 patients who underwent surgical percutaneous drilling because of chronic lateral epicondylitis between 2018 and 2021. The patients were evaluated with respect to demographic characteristics, including age, gender, body mass index (BMI), occupation, education level, hobbies, dominant side, and smoking status. The VAS (Visual Analog Scale) pain scores, PRTEE score (Patient-Rated Tennis Elbow Evaluation - a lateral epicondylitis function scale), and Roles-Maudsly score were examined preoperatively and at one and 12 months postoperatively together with grip strength measured with a Jamar hand dynamometer. Statistically significant improvements were determined in the VAS score during activity from 8.9 preoperatively to 2.06 at 12 months postoperatively (p<0.01), and in the PRTEE score, from 64.12 preoperatively to 20.61 at 12 months postoperatively (p<0.01). The Roles-Maudsly score at 12 months postoperatively was determined to be excellent in 13 (41.9%) patients, and good in 14 (45.2%). Mean grip strength increased from 69.55 before treatment to 90.97 at the end of 12 months postoperatively. Autobiological treatments are at the forefront of current treatments for tendinopathies. Percutaneous drilling is a closed method and can be considered an ideal method in the treatment of tendinosis caused by inflammation and mesenchymal stem cells (MSCs) contained in hematoma. It is also an advantageous treatment method for patients with aesthetic concerns as it does not leave any scar tissue and has a low risk of complications.

Eploring Determinants of Adherence to Medical Regimens in Patients with Chronic Conditions Beyond Hypertension and Diabetes

Chronic diseases are significantly increasing globally and increasing premature deaths among population. CDC has defined chronic diseases are the conditions that last 1 year or more and require ongoing medical support or limit the daily activities or both. Diabetes and hypertension are popular chronic diseases. But there are many others are also now increasing. The current study was conducted to find out the prevalence of noncompliance among chronic diseases like thyroid diseases, Asthma, COPD, Orthopedic problems and epilepsy. Also to understand the determinants factors among them. It was a hospital based cross sectional study. The sample size was calculated and it was 36 for each disease. Total 40 study participants of each disease were included. It was randomly selected the individuals diagnosed with the mentioned chronic diseases who have been diagnosed and on treatment for more than 3 years from hospital. Result: A total of 200 patients participated in the study. The study included 40 patients from each chronic disease that is thyroid disorders, COPD, Orthopedic problems, Asthma and Epilepsy. The rural population comprised 69% of the total study group. The prevalence of medical noncompliance was found in 56.5% of all the patients. People having the disease for longer period of time were more non-compliant. The study revealed that family support and regular follow up with doctor are two important determinates factors which has positive impact on compliance. Conclusion: Noncompliance to medication regimen among chronic disease patients is an important issue for public health consideration. This current study recorded an overall noncompliance level of 57.5%. The factors identified as contributing to medication noncompliance in this study were regular follow ups, family support, adequate knowledge regarding their disease and importance of taking medication with or without symptoms.

Prevalence of Femoral Anteversion along with Tibial Torsion in Flat Foot Individuals

Objective: To study the prevalence of femoral anteversion and tibial torsion in flat-foot individuals. Methods: This project was done among individuals having flat feet. All the genders were included in the study. Flat-foot individuals of the age group 20-30 years were included. Flat-foot individuals with any other orthopaedic problems were excluded from the study. After obtaining ethical permission, the consent form was filled out by all the subjects. A structured assessment was used for assessing the individuals having flat feet, after which segregation was done in that group and the individuals having tibial torsion were included and then the femoral anteversion was checked among the group. Results: Among 80 subjects, the finding of this study revealed that there is a prevalence of femoral anteversion along with tibial torsion in flat-foot individuals. The group analysis demonstrated statistically significant impairments in all the outcome measures. After obtaining permission from the ethical committee, the subjects fulfilling inclusion criteria were explained about the study and a structural assessment was conducted, revealing a significant correlation among the Feiss line test, femoral anteversion test and tibial torsion test. Conclusion: Flat-foot individuals have femoral anteversion among various individuals. The prevalence of flat-foot individuals having femoral anteversion along with tibial torsion is predominantly higher among the group.

How Informal Carers Support Video Consulting in Physiotherapy, Heart Failure, and Cancer: Qualitative Study Using Linguistic Ethnography.

Informal carers play an important role in the everyday care of patients and the delivery of health care services. They aid patients in transportation to and from appointments, and they provide assistance during the appointments (eg, answering questions on the patient's behalf). Video consultations are often seen as a way of providing patients with easier access to care. However, few studies have considered how this affects the role of informal carers and how they are needed to make video consultations safe and feasible. This study aims to identify how informal carers, usually friends or family who provide unpaid assistance, support patients and clinicians during video consultations. We conducted an in-depth analysis of the communication in a sample of video consultations drawn from 7 clinical settings across 4 National Health Service Trusts in the United Kingdom. The data set consisted of 52 video consultation recordings (of patients with diabetes, gestational diabetes, cancer, heart failure, orthopedic problems, long-term pain, and neuromuscular rehabilitation) and interviews with all participants involved in these consultations. Using Linguistic Ethnography, which embeds detailed analysis of verbal and nonverbal communication in the context of the interaction, we examined the interactional, technological, and clinical work carers did to facilitate video consultations and help patients and clinicians overcome challenges of the remote and video-mediated context. Most patients (40/52, 77%) participated in the video consultation without support from an informal carer. Only 23% (12/52) of the consultations involved an informal carer. In addition to facilitating the clinical interaction (eg, answering questions on behalf of the patient), we identified 3 types of work that informal carers did: facilitating the use of technology; addressing problems when the patient could not hear or understand the clinician; and assisting with physical examinations, acting as the eyes, ears, and hands of the clinician. Carers often stayed in the background, monitoring the consultation to identify situations where they might be needed. In doing so, copresent carers reassured patients and helped them conduct the activities that make up a consultation. However, carers did not necessarily help patients solve all the challenges of a video consultation (eg, aiming the camera while laying hands on the patient during an examination). We compared cases where an informal carer was copresent with cases where the patient was alone, which showed that carers provided an important safety net, particularly for patients who were frail and experienced mobility difficulties. Informal carers play a critical role in making video consultations safe and feasible, particularly for patients with limited technological experience or complex needs. Guidance and research on video consulting need to consider the availability and work done by informal carers and how they can be supported in providing patients access to digital health care services.

Reconstruction of gap non-union tibia with composite use of extramedullary fixation and bone transport by monorail fixator: a prospective case series.

Non-union is a complex, multifactorial orthopaedic problem that requires multiple treatment modalities for its management. It can result from infection, segmental bone loss, soft-tissue loss, and associated host factors. External fixators as management of gap non-union are bulky and give rise to a number of complications In our study, we have described a technique where we have used extramedullary fixation in the form of a tibial locking plate and transportation of part of the tibial bone after corticotomy by a monorail fixator. The procedure was done in two stages where internal and external fixation was done after creating a gap at the non-union site. The bone was transported after corticotomy and fixed to the internal fixation device in the second stage. The external fixator was removed in the second stage and the patient was then followed up till the bony union. The evaluation was done by functional and radiological assessment along with the complications noted with the described procedure. Ten patients were enrolled in the study with a mean age of 33 years. The mean age of the patients was 33.7 ± 11.32 years with a mean size of the defect was 4.8 ± 1.7 cm. At 30 weeks out of nine patients, three patients had excellent and six had good functional results on the Association of Surgeons for Application and Methodology of Ilizarov (ASAMI) scale. The composite Musculoskeletal Tumor Society (MSTS) score was 76.66 % at the end of 30 weeks of follow-up. The mean time of consolidation was 134.4 days, whereas the mean union time was 145 days from index surgery. Ankle stiffness was the most common complication affecting 50% of the patients. Following closely was pin tract infection, which was present in 40% of the patients. According to Paley's classification, there were 11 obstacles, two problems and none were true complications. The integrated fixation is both safe and effective and has the advantage of early removal of the external fixator and a low complication rate as compared to use of a bulky conventional fixator alone. Moreover, it gives protection to the regenerated bone for a long period. So, this technique can be recommended for the management of segmental tibial defects.